Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011.

In the European Union (EU) 72,334 tuberculosis (TB) cases were notified in 2011, of which 16,116 (22%) had extrapulmonary tuberculosis (EPTB). The percentage of TB cases with EPTB ranged from 4% to 48% in the reporting countries. This difference might be explained by differences in risk factors for EPTB or challenges in diagnosis. To assess the practices in diagnosis of EPTB we asked European Union/European Economic Area (EU/EEA) countries to participate in a report describing the diagnostic procedures and challenges in diagnosing EPTB. Eleven EU Member States participated and reports showed that in the majority EPTB is diagnosed by a pulmonologist, sometimes in collaboration with the doctor who is specialised in the organ where the symptoms presented. In most countries a medical history and examination is followed by invasive procedures, puncture or biopsy, to collect material for confirmation of the disease (by culture/histology/cytology). Some countries also use the tuberculin skin test or an interferon-gamma-release-assay. A wide variety of radiological tests may be used. Countries that reported challenges in the diagnosis of EPTB reported that EPTB is often not considered because it is a rare disease and most medical professionals will not have experience in diagnosing EPTB. The fact that EPTB can present with a variety of symptoms that may mimic symptoms of other pathologies does pose a further challenge in diagnosis. In addition, obtaining an appropriate sample for confirmation of EPTB was frequently mentioned as a challenge. In summary, diagnosis of EPTB poses challenges due to the diversity of symptoms with which EPTB may present, the low level of suspicion of clinicians, and due to the difficulty in obtaining an adequate sample for confirmation.

Tuberculosis in young adults and the elderly. A prospective comparison study.

OBJECTIVES: To compare the clinical, bacteriologic, and radiologic features of pulmonary and pleural tuberculosis in young adults and the elderly and determine if any differences exist between both groups. DESIGN: Prospective recruitment of all patients diagnosed as having pulmonary and pleural tuberculosis in British Columbia, Canada. SETTING: A population-based sample from a provincial control program TB registry. PATIENTS: A total of 218 consecutive patients whose conditions were diagnosed between January 1990 and May 1991. We excluded 15 HIV-positive patients whose conditions were diagnosed during this study. INTERVENTION: Standardized data collection of symptoms, bacteriology, and review of radiology by two readers blind to the clinical and epidemiologic data. MAIN RESULTS: There were 142 young adult patients and 76 elderly patients. The young adults had a mean age of 41.2 years and the elderly group had a mean age of 75 years of age. Fever (p = 0.002) and night sweats (p = 0.02) were more common in young adults. In culture-proven disease, hemoptysis, fever, and cough were more common in young adult (p = 0.03, 0.02, and 0.01, respectively). There was no difference in the duration of symptoms between the two groups. The odds ratio for cancers other than lung cancer, 3.98 (confidence interval, 1.49, 10.65) in the elderly group was the only significant risk factor to differ between the two groups. Skin test responses to 5TU PPD were positive in 86.2 percent of young adults and 67.6 percent of elderly patients tested (p = 0.03). A total of 79.6 percent of young adults and 88.15 percent of the elderly patients (not significant) were culture positive. Comparison of radiologic findings in young adults vs elderly patients showed no significant differences apart from those with miliary TB 0.7 percent vs 6.7 percent (p = 0.04). CONCLUSIONS: In this population-based study, young adults were more likely to have hemoptysis, fever, and cough and to have a positive PPD response. Cancer was significantly associated as a risk factor in the older age group. There was no difference in bacteriologically proven disease or radiologic findings between the two groups, apart from the more common occurrence of miliary TB in the elderly.

[Pulmonary alveolar proteinosis]. / Proteinoza pecherzyków plucnych.

Pulmonary alveolar proteinosis (PAP) is a rare disease characterised by the accumulation of proteinaceous material within alveoli. In order to evaluate the clinical features and the course of PAP we reviewed 7 cases (2F/5M) diagnosed during a 11-year period (1989-1999). The mean age of patients was 40.7 +/- 11.2 years. Diagnosis was obtained by open lung biopsy in all cases. Clinical findings included dyspnea (43%), cough (28%) and crackles (28%). Lung function tests were normal in 5 cases and showed a moderate restrictive pattern in 1 and mild airflow obstruction in 1. Three patients had reduced Dlco (mean was 63% of predicted). Four patients had hypoxemia at rest. Chest X-ray revealed bilateral alveolar opacities (71%), involving perihilar areas and lower lobes. HRCT scans demonstrated diffuse ground glass opacities (83%) with interlobular septa thickening (50%). Three patients were treated with repeated segmental BAL (2 improved). The spontaneous partial remission occurred in 4.

[Reasons for chronic expectoration in patients with pulmonary tuberculosis registered in the Central Tuberculosis Registry]. / Przyczyny przewleklego pratkowania u chorych na gruzlice pluc zarejestrowanych w Centralnym Rejestrze Gruzlicy.

The aim of the retrospective population-based study was to identify reasons for failure of sputum culture negativity from the 12th month on since the start of chemotherapy of pulmonary tuberculosis (PTB). Medical records of 97 patients with PTB (85 men and 12 women) remaining sputum culture positive for over 12 months, reported to the Central TB Registry (1988-1990), were reviewed. The mean age was 46.7 years. There were 39.2% blue collar workers, 18.6% peasants, 21.6% unemployed, 14.4% pensioners. Only 4.1% constituted persons with education above elementary level. 44 patients abused alcohol, 13 of them had severe alcohol related health problems. Initial susceptibility tests were done in 79 subjects, showing resistance to at least one drug in 15. In 21 subjects the new resistance occurred during observation. The mean period until conversion of sputum culture was 23.5 months. Sputum culture conversion was finally achieved in 63 (64.9%) subjects. The reasons for delayed sputum culture conversion were identified in 86 persons. The main reason for long duration of positive sputum culture in 75 (87.2%) subjects was poor compliance. In 7 (8.1%) cases evident treatment error was relevant. Serious adverse reactions to drugs were responsible in 4 (4.6%).

[Prevalence of diagnosing extrinsic allergic alveolitis in Poland in the years 1990-1994]. / Czestosc rozpoznawania alergicznego zapalenia pecherzyków plucnych W Polsce, w latach 1990-1994.

Poland is the country, where almost 40% of population inhabit rural areas. So EAA may be an important health problem. The aim of the study was to assess incidence of EAA in different districts in Poland. We asked hospitals to send us lists of patients with diagnosis of EAA established in the period of 1990-1994. In some hospitals we collected information by ourselves. This way, we have got data concerning patients with EAA. The highest prevalence of EAA 1.5-7.0/100,000 population was observed in eastern and south-western regions of Poland. Eastern Poland is rural area with small not specialised farms and possible high exposure to EAA antigens. In south-western Poland (Silesia) keeping pigeons is a very popular hobby, which may explain high incidence of EAA.

[Dyspnea, respiratory mechanics and gas exchange in patients with idiopathic pulmonary fibrosis]. / Dusznosc, mechanika oddychania i wymiana gazowa u chorych na samoistne wlóknienie pluc.

The sensation of dyspnea on exertion is usually the first clinical symptom in patients with IPF. The aim of the study was to assess breathlessness in patients with IPF at the time of diagnosis. The study group included 9 patients (5 women and 4 men), aged 61.4 +/- 10.5 (mean +/- SD) yrs, (range 38-71 yrs). FVC was 65.8 +/- 8.3% pred., FEVI 70.0 +/- 9.0% pred., TLC 65.1 +/- 10.5% pred. 6 min walking test was performed, during which pts reported their breathlessness according to Borg scale. All patients but one reported breathlessness during exercise. Patients were divided into two groups according to the level of dyspnea at the end of the walking test. Patients with dyspnea equal or less than moderate (= < level 3 Borg scale) had significantly higher lung volumes FVC (2.57 +/- 0.44 vs 1.79 +/- 0.5 l, p < 0.05), FEVI (2.23 +/- 0.29 vs 1.56 +/- 0.36 l, p < 0.02), TLC (4.26 +/- 0.26 vs 3.13 +/- 0.69 l, p < 0.02), DLCO (4.49 +/- 0.52 vs 3.43 +/- 0.23 mmol/min/kPa, p < 0.02), and smaller alveolar-arterial oxygen tension difference at rest (31.8 +/- 5.6 vs 43.8 +/- 2.8 mmHg, p < 0.01) as compared to the patients with more severe dyspnea (> level 3 Borg scale). All patients desaturated during the test, but there was no correlation between the degree of desaturation and dyspnea level at the end of the test. 4 patients from the first group (dyspnea level = < 3 Borg scale) desaturated from 6.3% to 19.4% from baseline value. So patients with IPF may experience severe desaturation during normal daily activity not being aware of it. Dyspnea on exertion in these patients seems to depend on both disturbed lung mechanics and gas exchange. Simple 6-minutes walking test proved to be useful in assessing severity of the disease in patients with IPF.

[Bronchiolitis obliterans organizing pneumonia]. / Zarostowe zapalenie oskrzelików z organizujacym sie sródmiazszowym zapaleniem pluc.

Idiopathic BOOP is a clinicopathological entity defined histopathologically by the presence of granulation tissue in bronchioles, alveolar ducts and alveoli. 2 men and 6 women (mean age 47.2 years, range 22-66) with idiopathic BOOP have been observed, the mean period of observation being 31.1 months. In 7 cases the disease started with fever, cough and in 6 with progressive dyspnea. The interval between the onset of symptoms and the beginning of treatment ranged from 2 to 10 months. One woman was asymptomatic. The initial findings were: tachypnoea (6), crackles (7), decreased VC (6), reduced diffusing capacity (6), raised erythrocyte sedimentation rate (7). In 6 cases chest radiographs showed multiple alveolar patchy opacities of various size predominantly in the middle and lower lung zones. HRCT demonstrates peripheral distribution of changes. In one case diffuse reticulonodular infiltrates and in one case solitary tumor-like opacity with cavitation were observed. Seven subjects were given prednisone. Three subjects recovered completely, in 1 clinical and radiological improvement was observed. In 3 cases relapse occurred. The woman with the solitary tumor-like opacity was cured by surgical excision of the lesion.

[Incidence of tuberculosis in patients with hematologic malignancies]. / Czestosc wystepowania gruzlicy u chorych na nowotwory ukladu krwiotwórczego.

The analysis of the incidence of tuberculosis in patients with hematological malignancies was performed in 2,025 patients hospitalized in internal clinic. Only in 42 cases tuberculosis was noticed.

[Pulmonary lymphangioleiomyomatosis: presentation and results of treatment]. / Limfangioleiomiomatoza pluc: obraz kliniczny i wyniki leczenia.

Lymphangioleiomyomatosis is a rare lung disease of unknown aetiology that affects only women. Eight premenopausal women with LAM confirmed by lung biopsy specimens were observed in 1984-2001. The most common presenting feature was exertional dyspnea (6) followed by chylous pleural effusions and pneumothoraces. In two women severe airflow obstruction was observed at presentation. HRCT revealed characteristic cysts in all cases. All women were given hormonal therapy (tamoxifen, medroxyprogesterone). The best results of treatment were achieved in cases with chylothoraces.

[Effect of electrical damage to catecholaminergic structures on aggressiveness in rats following administration of isoniazide]. / Wplyw uszkodzen elektrolitycznycii struktur katecholaminergicznych na zachowania agresywne szczurów po podaniu hydrazydu kwasu izonikotynowego.

The author studied the effect of INH administered in single and repeated doses on affective aggressiveness. INH's effect on predatory aggressiveness was evaluated following administration of the drug in a single dose in three different doses. Affective aggressiveness was provoked by pain stimulus, predatory aggression by chronic isolation. In order to evaluate the role of catecholaminergic neurons in INH's effect on affective aggression, electrical damage of structures known to have such neurons was carried out. INH was administered in a single and in multiple doses increasing affective aggressiveness in rats. This was intensified by destruction of the nucleus locus coeruleus and decreased by destroying ventral parts of the noradrenergic and dopaminergic pathways of the A-10 structure. INH decreased predatory aggressiveness of rats. The results of this study demonstrate the role of catecholamines in INH influence on aggression, showing also different roles of both studied neurological structures in regulation of aggression in rats.

[Effect of drugs with a known mechanism of action on catecholamine receptors on aggressive behavior in rats following administration of isoniazid]. / Wplyw leków o znanym dzialaniu na receptory katecholaminergiczne na zachowania agresywne szczurów po podaniu hydrazydu kwasu izonikotynowego.

The participation of catecholaminergic neurones in effect of INH on affective aggression was studied using agents known to act on noradrenergic (clonidine, prazosin) and dopaminergic receptors (sulpiride, spiroperidol). The above mentioned agents blocked affective aggression in rats after administration of INH. The results of this study imply that both catecholamines participate in INH induced affective aggression.

[Cavernous changes as a result of pulmonary tissue hyperreactivity to Aspergillus fumigatus infection]. / Postepujace zmiany jamiste w plucach jako wyraz nadwrazliwosci tkanki plucnej na Aspergillus fumigatus.

A case report is presented of a 74 year old male with chronic bronchitis in whom fever, malaise and sputum hypersecretion was observed. Inflammatory changes in the right upper lobe were found on a chest radiogram. Broad spectrum antibiotics and antituberculous agents did not produce any improvement. Due to the fact that Aspergillus fumigatus organisms were cultured from the sputum and the precipitin test was positive to aspergillin the diagnosis of Aspergillus fumigatus infection was made. 5-fluorocytosine--Ancotil did not bring any improvement. After initiating steroid therapy with 30 mg of prednisone an improvement was observed. This allowed to diagnose hyperreactivity to Aspergillus fumigatus as the cause of the disease.

[A case of skin cryptococcosis in systemic lupus erythematosus]. / Przypadek kryptokokozy skóry w przebiegu ukladowego tocznia rumieniowatego.

Here is presented a case of woman treated by immunosuppressive preparations because of systemic lupus erythematosus with ski manifestations as tubercles and ulcerations on skin of trunk and extremities. On the basis of histological examination of tubercle skin specimens and mycological examinations of material obtained from skin ulcerations cryptococcosis was diagnosed. Disease was limited to skin that was an entry of infection. Patient was treated by Amphotericin B administered intravenously and Flucitosine per os. Amphotericin B was also applied topically. The results of cultures became gradually negative, up to total disappearance of fungus cells in direct specimens, prepared from examined material. After treatment continuing for 5 months only discoloured scars were observed on sick skin.

[Langerhans Cell Histiocytosis in adults]. / Histiocytoza komórek Langerhansa u doroslych.

Five cases of Langerhans' cell histiocytosis in adult patients were reviewed. Signs, symptoms, the course of the disease and methods of treatment were presented. Results of tests, including results of organ biopsies that provided definitive diagnosis in most cases, were also analysed.

[The course of allergic alveolitis based on personal experience]. / Przebieg alergicznego zapalenia pecherzyków plucnych w swietle wlasnych doswiadczen.

The course of allergic alveolitis was observed in 19 patients. The diagnosis was based on medical history, exposition to organic dust, clinical findings, respiratory function and in selected cases on results of transbronchial lung biopsy. All patients presented restrictive patterns of lung function abnormalities. Although a clinical improvement was seen, in none of the patients was a normalization of respiratory function observed. The results of treatment were more promising in patients with a shorter time between the onset of symptoms and making of diagnosis. Isolation from allergens resulted in better effect without prophylactic treatment with prednisone. Steroid therapy did not effect the relapses nor worsening of the respiratory function.

Radiologic features of pulmonary tuberculosis: an assessment of 188 cases.

To assess the radiologic patterns of presentation of active pulmonary tuberculosis, the authors studied all patients with active, culture-proven pulmonary tuberculosis who presented in British Columbia between May 1989 and May 1991. The chest radiographs were assessed by two observers. Epidemiologic data were collected to allow examination of differences among ethnic groups. The 188 patients ranged in age from 1 to 96 (median 54) years; only 2 were less than 20 years of age. Thirty of the 188 patients (16%) presented with clinical and radiologic findings consistent with primary tuberculosis; the other 158 (84%) had postprimary disease. Of the second group, typical upper lobe infiltrates were seen in 126 (80%). Less common manifestations included lymphadenopathy (in 14 cases), isolated nodular tuberculoma (in 10), isolated involvement of the lower lung zones (in 10), cavities with air-fluid levels (in 6) and isolated pleural effusion (in 2). The authors conclude that the characteristic upper lobe infiltrates of postprimary disease remain the most common form of presentation of active tuberculosis in adults. However, atypical presentation, due to either an unusual pattern of postprimary tuberculosis or to primary tuberculosis, may be seen in up to 30% of patients.

[Pulmonary manifestations of polymyositis and dermatomyositis: a report of 6 cases and a review of literature]. / Zmiany plucne u chorych na zapalenie wielomiesniowe lub skórno-miesniowe: opis 6 przypadków i przeglad pismiennictwa.

The group of 6 patients with interstitial pulmonary changes in the course of polymyositis or dermatomyositis treated in years 1986-1999 was assessed. In one woman pulmonary changes occurred ten years before other symptoms of the connective tissue disease. Lung function tests showed a restrictive ventilatory defect in all patients. High resolution computed tomography revealed different changes, from ground glass attenuation to honey--combing. Only one patient, probably with bronchiolitis obliterans organizing pneumonia, responded to corticosteroids. Four women died from respiratory failure. In 2 pneumomediastinum occurred, which is a rare complication.